AFFIRMATIVE ACTION DATA
Please complete and return this form with your employment application materials. Submission of this
statistical information is voluntary; failure to complete this form will not adversely affect your candidacy
for employment.
Name (Print): _________________________________________________________________________
Position Applied For: _________________________________________________________________
The Evergreen State College is an equal opportunity employer. The College’s state-approved Affirmative
Action Program seeks to ensure that employment opportunity information reaches all qualified potential
candidates without regard to race, color, religion, sex, sexual orientation, gender identity, national origin,
age, genetic information, disability, or veteran status. To implement this program more successfully, the
college requests that you provide the following information.
This information will be separated from your application and handled confidentially for statistical purposes.
How did you first learn of this position? _________________________________________________
Please check any/all of the following that apply:
Male
Female
African American/Black
Asian
Pacific Islander
Age 40 or older
Caucasian/White
Hispanic/Latino
Native American/American Indian/Alaska Native
Categories of protected veterans (check one of the following):
I identify as one or more of the classifications of protected veteran listed
below
I am not a protected veteran
I choose not to self-identify
This employer is a Government contractor subject to the Vietnam Era Veterans’ Readjustment
Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C. § 4212
(VEVRAA), which requires Government contractors to take affirmative action to employ and advance
in employment: (1) disabled veterans; (2) recently separated veterans; (3) active duty wartime or
campaign badge veterans; and (4) Armed Forces service medal veterans. These classifications are
defined as follows:
1. “disabled veteran” is one of the following: a veteran of the U.S. military, ground, naval or air
service who is entitled to compensation (or who but for the receipt of military retired pay would
be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or a
person who was discharged or released from active duty because of a service connected
disability.
2. “recently separated veteran” means any veteran during the three year period beginning on the
date of such veteran’s discharge or release from active duty in the U.S. military, ground, naval,
or air service.
3. An “active duty wartime or campaign badge veteran” means a veteran who served on active duty
in the U.S. military, ground, naval or air service during a war, or in a campaign or expedition for
which a campaign badge has been authorized under the laws administered by the Department of
Defense.
4. An “Armed forces service medal veteran” means a veteran who, while serving on active duty in
the U.S. military, ground, naval or air service, participated in a United States military operation
for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.
Protected veterans may have additional rights under USERRA—the Uniformed Services Employment
and Reemployment Rights Act. In particular, if you were absent from employment in order to perform
service in the uniformed service, you may be entitled to be reemployed by your employer in the position
you would have obtained with reasonable certainty if not for the absence due to service.
For more information, call the U.S. Department of Labor’s Veterans Employment and Training Service
(VETS), toll free, at 1 866 4 USA DOL.
If you believe you belong to any of the categories of protected veterans listed above, please indicate by
checking the appropriate box above. As a Government contractor subject to VEVRAA, we request this
information in order to measure the effectiveness of the outreach and positive recruitment efforts we
undertake pursuant to VEVRAA.